Endovascular treatment of ruptured abdominal aortic aneurysm: is there a long-term benefit at follow-up?

AIM: Several studies have shown the feasibility of endovascular repair of ruptured abdominal aortic aneurysms (rEVAR). However, the role and value of rEVAR remains controversial due to selection bias and lack of long-term results. In the present study we describe our short- and long-term results of treating patients with rEVAR irrespective of hemodynamic condition and challenging anatomy. METHODS: In April 2006 we started the single centre prospective non-randomised Ruptured Aneurysm Study (RASA). During a four year enrolment period all consecutive patients presenting with infrarenal ruptured AAA (rAAA, N.=117) were assessed for preferential rEVAR treatment. A rAAA was defined as extravasation of blood or hematoma outside the AAA due to transmural tear in the infrarenal abdominal aorta wall documented by preoperative computed tomography (CT) angiography examination or during open repair. Patients with challenging anatomy (infrarenal neck length below 15 mm and neck angulation above 60 degrees) were included as part of a damage control concept. Complication and mortality rates were studied at 30 days and yearly afterwards. RESULTS: Thirty-five patients (33% of all admitted rAAA) were treated with rEVAR and 42% of them were considered hemodynamically unstable (systolic blood pressure <100 mmHg) and 30% had challenging AAA anatomy. The mortality rate at 30 days in the rEVAR group was 17%, in the open repair group 31%, and in the entire rAAA group (including abstained patients) 36%. During the first 30 days, 18 rEVAR patients experienced complications with nine re-interventions as a result. Long-term mortality of the rEVAR patients was 34% after a median follow-up of 3.4 years. All deaths after one year follow-up were non-AAA related. Multivariate analysis shows that Hardman index, presence of peripheral arterial obstructive disease and lowest systolic blood pressure during surgery are independently associated with long-term survival. Challenging rAAA anatomy was not associated with impaired survival. CONCLUSION: Our study shows that rEVAR is feasible irrespective of hemodynamic condition and that it is associated with relative low mortality rates. Challenging rAAA anatomy may not affect overall long-term survival, but six out of ten patients remain unsuitable for rEVAR because of inappropriate anatomy.

The Anaconda AAA stent graft system: 2-year clinical and technical results of a multicentre clinical evaluation.

INTRODUCTION: This study reports the technical and mid-term clinical results of the second-generation Anaconda AAA Stent Graft System endovascular device for treatment of abdominal aortic aneurysm (AAA). The design of the Anaconda AAA Stent Graft System is characterised by a three-piece system consisting of two proximal independent saddle-shaped nitinol self-expandable rings with hooks fixation, zero body support and vacuum-cleaner tube leg design. METHODS: From July 2002 to April 2005, a total of 61 patients with AAA were enrolled in a multicentre, prospective, non-randomised controlled design study. All patients received a second-generation Anaconda AAA Stent Graft System. They entered a standard follow-up protocol at discharge for 3, 6, 12 and 24 months. Follow-up data included survival; rupture-free survival; incidence of aneurysm rupture, death from aneurysm rupture, aneurysm-related death; freedom from aneurysm expansion; freedom from Types I and III endoleaks; endograft patency and technical and clinical success rates. RESULTS: Successful access to the arterial system was achieved in all patients. The primary technical success was 59 out of 61 and the primary assisted technical success was 60 out of 61. All endovascular grafts were patent without significant twists, kinks or obstructions. Migration was not observed in any of the grafts. During the first 30-day period, two serious adverse events (3%), both not related to the procedure, were observed. Nine patients (15%) needed a secondary intervention; two of these interventions were related to stent graft (3%). The mean aneurysm sac diameter decreased significantly from 57 mm pre-operative to 45mm after 24 months, without aneurysm growth. There was one Type I endoleak at initial implantation, which was corrected using a proximal extension cuff. In total, three Type II endoleaks were still present after 24 months without any signs of aneurysm growth. CONCLUSION: The design features of the second-generation Anaconda AAA Stent Graft System are effective in the treatment of AAAs on mid-term evaluation.

Validation of open-surgery VR trainer.

VREST (Virtual Reality Educational Surgical Tools) is developing a universal and autonomous simulation platform which can be used for training and assessment of medical students and for continuing education of physicians. With the VREST - Virtual Lichtenstein Trainer, simulating the open surgery procedure of the inguinal hernia repair according to Lichtenstein, the validation of the simulator is ongoing. Part of this trajectory is the evaluation of the transfer of training of the virtual incision making. One group of students trained incision making on the VREST platform where the control group did not. In an experiment both groups has to perform several incision tasks on a manikin. The results are not available yet but will be presented at the MMVR14 conference.

Open surgery in VR: inguinal hernia repair according to Lichtenstein.

VREST (Virtual Reality Educational Surgical Tools) is developing a universal and autonomous simulation platform which can be used for training and assessment of medical students and for continuing education of physicians. A workstation consisting of two haptic devices and a 3D vision system is part of the VREST platform. Another part of the platform is a generic software environment in which lessons can be built by the teacher and performed by their students. Using the platform one can see, feel and decide as in reality. With the assessment tool the progress and skills of the students can be supervised. The first lesson build on the VREST platform is an inguinal hernia repair according to Lichtenstein. This is an open surgery procedure. The VREST platform is used prior to the first operating room surgery of the resident. Interactive models and case dependent feedback is used to enlarge the residents' cognition. This should reduce the training time in the operating room.

The EAG tool: a decision support system for selection of abdominal aorta aneurysm endografts.

This article describes a decision support system (the EAG tool = Effective AAA Graftmanship) that assists the vascular surgeon in deciding whether a patient is fit for an endograft procedure and that assists the vascular surgeon in selecting the proper graft and in planning the endograft procedure. The EAG tool is the first step in the development of a learning environment for AAA procedures. As such the EAG tool is part of the VREST development project aiming to create a complete set of Virtual Reality Educational Surgical Tools. The EAG tool has been validated by using the expert knowledge of five experienced AAA physicians: three vascular surgeons and two interventional radiologists. In over 3,000 assessments, the EAG tool showed a false-positive rate of 0.2%, or in other words: in only 1 out of 500 cases the EAG tool indicated the possible use of an endograft, whereas the combined group of experts believed that it was not possibe. The EAG tool proved to be more prudent than the group of experts in having a false-negative rate of 3.7%. The EAG tool thus proved to be useful in daily clinical practice. Further developments are ongoing to use the EAG tool in a learning environment, specifically for unexperienced physicians.